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GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Advanced Emergency Trauma Course
GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD
ThoracicTrauma
Presenter:PatrickCarter,MD
Objectives
Epidemiology ChestWallInjury PulmonaryInjuries CardiovascularInjuries EsophagealInjuries
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.trauma.org/images/image_library/21223463721July_125.jpg
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Epidemiology Thoracictraumaresultsin20-25%ofdeathsduetotrauma
Accountsformorethan16,000deathsannuallyintheUnitedStates
Immediatetraumaticdeathisgenerallytheresultofruptureofmyocardialwallorthethoracicaorta.
Earlydeathswithin30min–3hoursaretypicallyduetotensionpneumothorax,cardiactamponade,airwayobstructionoruncontrolledthoracichemorrhage
EarlydeathsfromthoracicinjuryareoftenpreventableifappropriateEmergencyDepartmentandTraumacareisprovided.
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Chest Wall Injury Epidemiology• 50%ofpatientswiththoracictraumahavechestwallinjury
10%willhaveminortrauma 35%willhavemajortrauma 5%willhaveflailchestinjuries
AnatomyandPhysiology• Intactchestwallisnecessaryfornormalventilation
• Respiratorymusclescauseoutwardexpansionofthoracicwallanddescentofdiaphragmcausingnegativepressureandpassiveairentryduringrespiration
• Chesttraumawillimpactthenormalrespiratoryprocessandpreventadequateoxygenationandventilation
• Patientsabilitytocompensateforinjurydependsonrespiratoryreserve
ClinicalFeatures• Inspectthechestfor:
Adequatechestrise Respiratoryrate Tidalvolume
• Palpatefor: Deformity Tenderness Crepitus
• Auscultatefor: Lungsounds Heartsounds
SpecificInjuries• RibFractures• SternalFracture• FlailChest• Non-penetratingBallisticInjury
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Rib Fractures Epidemiology• Simpleribfracturesaccountformorethan50%ofnon-penetratingtrauma• Associatedinjuriesareimportanttoidentify-Pneumothorax/Hemothorax
Pathophysiology• Ribsbreakatpointofimpactorposteriorangle(weakeststructuralpoint)• Ribs1-3=Relativelyprotected=Higherassociationwithsevereintrathoracicinjury
• Ribs9-12=Moremobile=Higherassociationwithintra-abdominalinjury Rightsidedribfractures=3Xaslikelytohavehepaticinjury Leftsidedribfractures=4Xaslikelytohavesplenicinjury
• Fracturesmorecommoninadultsduetoinelasticityofthechestwall• Ribfractures=Highpotentialforpenetratinginjurytopleura,lung,liverorspleen
• Multipleribfractures(2ormore)isassociatedwithhigherincidenceofinternalinjury
• Elderlypatientswithmultipleribfractureshavefivefoldincreaseinmortalitycomparedwithyoungerpatients(<65)
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Rib Fractures ClinicalFeatures• Clinicalsuspicionwithtenderness,bonycrepitus,ecchymosisandmusclespasmovertherib
• Compressionoverthesiteofinjurytypicallycausespain DiagnosticStrategies• CXRismainstayofdiagnosis–Mainlytoevaluateforassociatedinjuries• Dedicatedribfilmsareoflimitedutility• Previouslyfracturesofribs1-2termedthehallmarkofseverechesttrauma
Requiredarteriographytoevaluateintrathoracicinjury Numerousstudieshavenowshownthatwithoutdirectevidenceofvascularorneurologiccompromisethatfractureof1stor2ndribisnotassociatedwithincreasedmortality
However,multipleribfracturesthatincludethe1stor2ndribisassociatedwith10foldincreaseinmortality
• HelicalCThaslargelyreplacedarteriographyfordiagnosisofmajorvascularinjuriesandpatientswithmultipleribfractureswithsuspectedvascularorintrathoracicinjuriesshouldundergoCTimaging
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Rib Fractures ClinicalCourse• Ribfractureshealin3-6weeks• Gradualdecreaseinpainovertimewithanalgesianeededforfirst1-3weeks
Management• Paincontrol(PONarcotics,IVNarcotics,IntercostalNerveBlocks)• Maintenanceofpulmonaryfunction• Binders,beltsandotherrestrictivedevicesshouldbeavoided.Theydecreasepainbutarenotedtohaveincreasedriskofhypoventilation,atelectasisandsubsequentpneumonia
• ElderlypatientsmayrequireadmissionfortreatmentwithIVpaincontrolandmonitoringofrespiratorystatus
• DisplacedribfracturesshouldbemonitoredandrepeatCXRat3hoursafterpresentationtoevaluatefordelayedpneumothoraxdevelopment
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Rib fractures 1stand2ndRibfracture,Smallapicalcapindicatinglocalizedhemorrhage
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://anaesthesia-drzek.blogspot.com/2008/09/fracture-rib.html http://anaesthesia-drzek.blogspot.com/2008/09/fracture-rib.html
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Sternal Fracture Epidemiology• Primarily,theresultofanteriorblunttrauma
• E.g.Passenger’scheststrikessteeringwheel• Increasedriskofsternalfracturewithuseofpassengerrestraint
Threefoldincreasesincewidespreadseatbeltuse Expectdecreasewithairbagdeployment(nodatayet)
• SternalFracturesmorecommoninolderpatientssufferingblunttrauma(Lesselasticchestwalldoesn’tdistributeforceevenly)
Pathophysiology• Rapiddecelerationinjuryfromafrontalimpactresultsinsternalfractureatsiteofseatbelt
• Isolatedsternalfracturesarerelativelybenignwithlowmortality(0.7%)
• Complications MyocardialContusion(1.5-6%ofcases) SpinalFractures(<10%ofcases) RibFractures(21%ofcases) Noassociationbetweensternalfractureandbluntaorticinjury
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Sternal Fracture Pathophysiology(continued)• Associatedmediastinalinjuriesshouldbeconsideredincludingmediastinalhematomafrominjurytounderlyingproximalgreatvessels
ClinicalFeatures• Anteriorchestpainandpointtendernessoverthesternum,softtissuedeformity
DiagnosticManagement• Lateralradiographismosthelpfulwithdiagnosisduetotransversenatureofmostfractures
• PatientswithsternalfractureshouldbescreenedformyocardialcontusionwithEKGandserialcardiacenzymes
Management• Analgesia• Withoutanyassociatedinjuries,patientswithisolatedsternalfracturescanbedischarged
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Sternal Fracture PectusExcavatum SternalFracture
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.jssm.org/vol4/n3/14/F1.htm
www.radrounds.com
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Flail Chest Epidemiology• Occursin1/3ofmajortraumapatientswithmajorchestinjuries
Pathophysiology• Threeofmoreadjacentribsarefracturedattwopoints,resultinginafreelymovingsegmentofchestwall
• Segmentmovesinparadoxicalmotionwithunderlyingnormalchestmovement
• Highassociationwithunderlyingpulmonarycontusion• Underlyingpulmonarycontusionismajorcauseofrespiratoryinsufficiency
• Severepainassociatedwithinjuryresultsinmuscularsplintingandresultantatelectasisandhypoxemia
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Flail Chest ClinicalFeatures• Examineforparadoxicalsegmentmovement• Pain,tendernessandcrepitusareoftenseen
DiagnosticStrategies• CXRwilloftenshowmultipleribfracturesandunderlyingpulmonarycontusion
• CTscan–moreaccuratethanCXRandwillhelpdefineextentofunderlyinginjury
Management• Aggressivepulmonaryphysiotherapy• Effectiveanalgesia• Selectiveuseofmechanicalventilationandendotrachealintubation• Closeobservationofrespiratorystatus• Earlyoperativefixationofflailsegmentresultsinquickerrecovery,decreasedcomplicationsandimprovedcosmeticandfunctionalresults
• Mortalityassociatedwithflailchest=8-35%andisdirectlyrelatedtounderlyinginjuries
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Flail Chest
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
PulmonaryContusion
http://virtual.yosemite.cc.ca.us/lylet/rc211/Case1FlailChest.gif
Non-penetrating Ballistic Injury Definition• Non-penetratingballisticinjuryincludesinjuryfrom:
Rubberbullets(Usedbypoliceforcrowdcontrol) Beanbagshotgunshells “BulletProofVests”=Bulletresistantvests
Pathophysiology• Projectileinjuryfrompenetratingbulletisinhibitedbynon-penetratingballisticinjuries
• Kineticenergyofprojectilecanbetransmittedthroughtopatientandstillcauseinjury
ClinicalFeatures• Erythema,EcchymosisandTendernessoverimpactedarea• Evaluateareaforanysubcutaneousemphysema,crepitisorbonystep-offs
DiagnosticStrategies• CXRtoevaluateforintra-thoracicinjuries,retainedforeignbodyorviolationofthebone
Management=CloseobservationGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Non-Penetrating Ballistic Injury RubberBulletInjuries
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.mindfully.org/Health/2002/Rubber-Bullets-Israeli-Arab25may02.htm
SourceUndeterminedGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Traumatic Asphyxia Pathophysiology
• Raresyndromecharacterizedbyseveresuddencompressionofthethoraxbyheavyobject
• Causesmarkedincreaseinthoracicandsuperiorvenacavalpressure• Retrogradeflowofbloodfromrightheartintogreatveinsofheadandneck
ClinicalFeatures• Deepvioletcolorofskinoftheheadorneck• Bilateralsubconjunctivalhemorrhages,PetechiaeandFacialEdemaaretypicallypresent,indicativeofsuddenincreaseinbloodflow
• BenignandSelf-limitedcondition Diagnosis
• Clinicalsignificanceisindiagnosingintrathoracicinjuryfromseverityofforcerequiredtocausetraumaticasphyxia
• Chestwallandpulmonaryinjuriesaremostcommon• Neurologicbleedingisrare• CTImagingshouldbeobtained
Management• Neurologicmanifestationsresolvewithin24-48hours• Mainstayoftreatmentistreatmentofunderlyinginjuriesandsupportivecare
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Pulmonary Injuries
SubcutaneousEmphysema PulmonaryContusion Pneumothorax Hemothorax TracheobronchialInjury
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Subcutaneous Emphysema Pathophysiology• Subcutaneousemphysemainthepresenceofthechestwallisindicativeofamoreseriousthoracicinjury
• Typeofairentry Extrapleural
• Tracheobronchialtreeinjuryallowsairtoleakintomediastinumandthenuptothesofttissuesofanteriorneck
Intrapleural• Intrapleuralleakagetypicallycreatesapneumothoraxandthenairleaksthroughtheparietalpleuraandintothethoracicwall
• Location Adjacenttopenetratingwound
• Mayindicatelocalizedinfiltrationfromexternalenvironment Localizedsubcutaneousairoverchestwall
• Indicatespresenceoftraumaticpneumothorax Localizedoversupraclavicularareaandanteriorneck
• Typicallyindicatespneumomediastinum Massivesubcutaneousairofthefaceandneck
• TypicallytheresultofrupturedbronchusGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Subcutaneous Emphysema Diagnosis• Palpationofchestwallandneckrevealscrepitance• AuscultationmayrevealHamman’scrunchindicativeofairinmediastinum
• CXRmayshowsubcutaneousairtrackingthroughsofttissue
Management• Mostlysubcutaneousairisbenignandselflimitedandcanbetreatedwithhighflowoxygen
Facilitatesre-absorptionofnitrogenfromtissues• Keyisidentifyingunderlyinginjury• Massiveaccumulationsmaybeuncomfortabletoapatient
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Subcutaneous Emphysema
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.trauma.org/index.php/main/images/C11/
SourceUndetermined
http://www.trauma.org/index.php/main/images/C11/
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Pulmonary Contusion Epidemiology
• Presentin30-75%ofpatientswithsignificantbluntchesttrauma• Mostcommonsignificantchestinjuryinchildren
Pathophysiology• Directbruiseofpulmonaryparenchymawithassociatedalveolaredemaandhemorrhage
ClinicalFeatures• Dyspnea,Tachypnea,Cyanosis,Tachycardia,Hypotension,ChestwallBruising• Hemoptysismaybepresentin50%ofpatients• Associatedwithflailchest
Diagnosis• Radiographicfindingsappearwithinminutesofaninjury• Patchyirregularalveolarinfiltratestofrankconsolidation• Alwayspresentwithin6hoursofinjury• CTisparticularlysensitiveatdiagnosis• DifferentiatefromARDSbytimecourse
Pulmonarycontusion<6hourspresent,resolvesin48-72hours ARDSonsetis24-72hoursafterinjury
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Pulmonary Contusion Management• RestrictionofIVFadministration• Vigoroustracheopulmonarytoilet,Suctioning• PainControl• Judicioususeofrespiratorysupportwithendotrachealintubationandmechanicalventilation
ConsiderdoublelumenETTwhenonlyonelungdamaged Allowsforcompensationfordifferencesincompliancebetweenlungs Avoidintubationifpossibleasincreasedmortalityfromintubationduetopneumonia,sepsis,pneumothorax,longerhospitalization
Complication=Pneumonia• Prophylacticantibioticsarenotrecommended
Prognosis• Mortalityofisolatedpulmonarycontusionis5-16%
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Pulmonary Contusion
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://upload.wikimedia.org/wikipedia/commons/f/f2/Pulmonary_contusion.jpg
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Pneumothorax Definition=Accumulationofairinthepleuralspace Epidemiology• 15-50%ofpatientswithseverechesttrauma
Pathophysiology• Traumaticpneumothoraxiscausedbyfracturedribthatisdriveninwardresultinginlacerationofpleura
• Alsooccurswithoutafractureswhenimpactisdeliveredatfullinspirationwiththeglottisclosed,leasingtotremendousincreaseinintra-alveolarpressureandsubsequentruptureofthealveoli
• Penetratingtraumasuchasagunshotwoundorknifeinjurymaycausedirecttraumatothepleura
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Pneumothorax TypesofPneumothorax• SimplePneumothorax
Nocommunicationwiththeatmosphereoranyshiftofmediastinalstructuresorthehemi-diaphragmfromaccumulatingair
Pneumothoraxgrading• SmallPneumothorax<15%• ModeratePneumothorax=15-60%• LargePneumothorax>60%
• CommunicatingPneumothorax(OpenPneumothorax) Pneumothoraxassociatedwithlossofintegrityofchestwall Oftentermedsuckingchestwound Resultsinlargefunctionaldeadspaceforthenormallungandsevereventilatorydisturbance
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Tension Pneumothorax TensionPneumothorax• Progressiveaccumulationofairunderpressurewithinthechestcavitywithshiftofmediastinalstructurestooppositehemithorax• Resultsincompressionofcontralaterallungandgreatvesselvenousreturn• Resultsindecreaseddiastolicfillingoftheheartandsubsequentdecreasedcardiacoutput• Leadstorapidonsetofhypoxia,acidosisandshock• CardinalPhysicalExamFindings
Tachycardia,JugularVenousDistension,Tachypnea AbsentBreathsoundsonipsilateralside HypoxiaandHypotension,followedbycardiacarrest
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Pneumothorax ClinicalFeatures• Chestpainandshortnessofbreatharemostcommonsymptoms• Spectrumofpresentation
SmallPTX=Absentclinicallyonexam TensionPTX=Acutelyillinminuteswithseverecardiovascularandrespiratorydistress
• Signsandsymptomsdon’talwayscorrelatewithsizeofpneumothorax• Physicalexam
Absentbreathsoundsoveraffectedside Hyperesonance Tachycardia Tachypnea
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Pneumothorax DiagnosticFeatures• CXRispreferredinitialstudy• Uprightfullinspiratoryfilmprovidesbestinitialstudy• Ifnon-diagnostic,expiratoryfilmmaymakethepneumothoraxmorevisiblebydecreasingthelungvolume• CTisverysensitiveatfindingsmallpneumothoraceseveninsupinepatient• Bedsideultrasound
Rapidminimallyinvasivewayofevaluatingforpneumothorax Primarilyusedtoexcludediagnosis Findingssuggestingthepresenceofapneumothoraxinclude
• Absenceofpleuralline• Absenceofpleuralsliding• Presenceofalungpoint(exclusivehorizontallines)
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Simple Pneumothorax
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.trauma.org/index.php/main/images/C11/
http://www.daviddarling.info/images/pneumothorax_radiograph.gif
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Open Pneumothorax
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.trauma.org/index.php/main/images/C11/ https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/12617-1/ACCP/IS0877A/lsn4_files/image002.jpg
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Tension Pneumothorax
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.trauma.org/index.php/main/images/C11/
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Pneumothorax Management• PenetratingTrauma/NoPneumothorax
IfCXRisnegative,Observationx3hrs,RepeatCXRpriortoD/c• SimplePneumothorax
Someauthorsadvocatechesttubeforalltraumaticpneumothoracies SmallPneumothorax• Somepeopleadvocatecarefulobservationifpatientissymptomsfreeanddoesnotneedanesthesiaorpositivepressureventilation• Smallapicalpneumothorax<25%mayalsobeobservedclosely• OccultCTdiagnosedPTXisalsosuggestedtobeamenabletoconservativetreatment• Ifpatientistoreceivepositivepressureventilationorhasevidenceofmulti-systemtrauma,chesttubeshouldbeplaced
Moderate/LargePneumothorax=ChesttubeGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Pneumothorax Management–OpenPneumothorax• Pre-hospitalsetting–Threesidedocclusivedressing Avoidconversiontotensionpneumothorax
• EDsetting–PlacementofChesttubeatsiteremotefromwalldeficit Dressingcanbeocclusivedressingofpetroleumgauzeifchesttubeisinplace
Neverpackthewound–dressingcanbesuckedintochestcavity
Endotrachealintubationforrespiratorysupport• Definitivesurgicalrepairofdeficit
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Pneumothorax Management–TensionPneumothorax• NeedleThoracostomy
2ndIntercostalSpace–Mid-clavicularLine• TubeThoracostomy
5thIntercostalSpace–AnteriorAxillaryLine
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.hcmc.org/manualHCMC/Procedure_Lab/thoracostomy_tube_files/image004.jpg
www.trauma.org/index.php/main/article/199/index.php?main/image/95/
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Hemothorax Definition=accumulationofbloodinthepleuralspaceafterbluntorpenetratingtraumaticinjury
Pathophysiology• Hemorrhagefrominjuredlungparenchymaismostcommoncausebutisusuallyself-limiting
• Othervesselsmaybesiteofinjuryincludingintercostalandinternalmammaryarteries
• Lesscommonly,majorvesselsorhilarvesselsaresiteofbleeding
ClinicalFeatures• Dependingonrateandquantityofhemorrhage,varyinglevelsofhemorrhagicshockareencountered
• Diminishedorabsentbreathsoundsonaffectedside
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Hemothorax Diagnosis• ClinicalDiagnosis–oftenenoughtoinitiatetreatment• CXR–initialdiagnostictest
200-300ccBloodrequiredtocausecostophrenicblunting Supinefilm–typicallybloodwilllayerposteriorlyandgeneratediffusehazinessthatcanbesubtle
• CT–mostsensitivetestbutoftennotabletobeobtainedifpatientunstable
Management• Tubethoracosomyfordrainageofaccumulatedblood
Largeborechesttube=36-40French Failuretoevaluatebloodmayleadtopleuraladhesions
• Urgentthoracotomyisindicatedwithmorethan1500ccofbloodoutputoninitialplacementofchesttubeormorethan200cc/hrfor3hours
• Restorationofcirculatingvolume• Auto-transfusionisoptionforpatientswithbriskbleedingandrequirementoftransfusiontomaintaincirculatingvolume
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Hemothorax
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://www.trauma.org/index.php/main/images/C11/
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Tracheobronchial Injury Epidemiology• Occurwitheitherbluntofpenetratingtraumatothechestorneck• MorethanhalfareresultofMVC• Rareentity-occurringin<3%ofpatientswithsignificantchesttrauma
• Mortality=10% Pathophysiology• Knifewounds=Injuryincervicaltracheawithtransectionoftrachealringsorcricoidcartilage
• GSW=Injurytotracheobronchialtreeatanypoint• MVC/BluntInjury=Suddendecelerationofthoraciccage,putstractionontracheaatthecarinaaslungsarepulledaway
Aselasticityoftracheobronchialtreeisexceeded,itruptures 80%oftheseinjuriesoccurwithin2cmofthecarina
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Tracheobronchial Injury ClinicalFeatures• Symptoms
MassiveAirLeak,HemoptysisandSubcutaneousEmphysema
• TwoclinicalPresentations Woundopensintopleuralspace–LargePTX• Chesttubefailstoevacuatethespaceandre-expandthelungcharacterizedbybronchopleuralfistulaorpersistentairleak
Completetransectionofthetracheobronchialtreebutlittlecommunicationwiththepleuralspace• Presentwithunexplainedatelectasisorpneumoniadaystoweeksafterinjury
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Tracheobronchial Injury Diagnosis• CXRmaydemonstratesecondaryfindings
i.e.Pneumothorax,Pneumomediastinum,etc• Definitivediagnosisismadewithbronchoscopy
Management• EndotrachealIntubation
Preferableifdonewithbronchoscopetoallowvisualizationoftubepassingbeyondsiteofinjury
Blindintubationrisksplacingendotrachealtubeintotransectedairway,falsepassageorconvertpartialtearintofulltear
• SurgicalRepair(Thoracotomy)
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Tracheobronchial Injury Tracheobronchialinjuryresultinginbilateralpneumothorax,pneumomediastinumandsubcutaneousair
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
http://commons.wikimedia.org/wiki/File:Bilateral_pneumothorax_pneumomediastinum.jpg
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Cardiovascular Injuries
BluntCardiacTrauma• MyocardialConcussion• MyocardialContusion• MyocardialRupture
PenetratingCardiacInjury AcutePericardialTamponade BluntAorticInjury
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Blunt Cardiac Trauma Epidemiology• TypicallyresultsfromhighspeedMVCwherechestwallstrikessteeringwheel• Firstcharacterizedassignificanttraumaticentityin1930’sbyBrightandBeck• Diagnosisisdifficultbecauseoflackofgoldstandardtestingformakingdiagnosis
ClinicalSpectrum• MyocardialConcussion• MyocardialContusion• TraumaticMyocardialInfarction• MyocardialRupture
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Myocardial Concussion Definition• CommotioCordis• Bluntinjurytochestproducesastunningtothemyocardiumanddysrhythmia
• Nopermanentcellularinjuryoccursbuttransientclinicaleffectsresult
Mechanism=Sharpdirectblowtothemid-anteriorchest• Resultsinabriefdysrhythmia,hypotensionandlossofconsciousness
Ifpatientsurvivesinitialdysrhythmia,nolastingpathologicchangesanddifficulttomakediagnosis
Myocardialconcussion=casesofsuddendeathafterablowtochestwithnochangesonautopsy
Treatment=CasereportsofsuccessfultreatmentwithrapidapplicationofCPRandautomateddefibrillator
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Myocardial Contusion Epidemiology• Poorlyunderstoodandnebulouscondition• Reportedincidence=3-55%inreportsofsevereclosedchesttrauma
Pathophysiology• Directblowtothechesttransmitsenergythroughtheribstothespineandcompressestheheartbetweenthesternumandvertebrae,resultingincardiacinjury
• Theseverityoftheinjuryisthoughttorelatetothephaseofthesystolic/diastoliccycleduringwhichthetraumaoccurs
• Injuriesoccurringduringthemorerigidstagesoflaterdiastoleandearlysystole(whentheheartisfilledwithblood,lesselastic)aremoredamaging.
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Myocardial Contusion Pathophysiology(Continued)• Rangeofmicrocellulardamageisseenfrommilddisruptionofmyofibrilstocompletelossofstructureandnecrosis
• Edemaandcellularinfiltratesaccumulateinthewalloftheheartandresultsindecreasedventricularcompliance
• Acutethrombusmayformandresultincoronaryarteryocclusionandmyocardialinfarction
• Smallpericardialeffusionsoccurinmorethan50%ofallcontusions(notindicativeofsignificantcardiacinjuryorincreasedriskoftamponade)
• Fibrousreactionmayoccuratthesiteofthemyocardialinjuryandsiteisatriskfordelayedrupture(typically2ndweekafterinjury)
• Mostmyocardialcontusionshealspontaneouslywithresolutionofcellularinfiltrateandhemorrhageleadingtoscarformation.
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Myocardial Contusion ClinicalFeatures• Mostpatientswithmyocardialcontusionwillhaveexternalsignsofthoracictraumaincludingcontusions,abrasions,ribfractures,etc.• Absenceofthoraciclesionsdecreasessuspicionbutdoesnotexcludecardiacinjury• Mostsensitivebutleastspecificsignofmyocardialcontusion=sinustachycardia
Presentin70%ofpatientswithdocumentedmyocardialeffusion
• Conductionblocksmayoccurbutisrarelyclinicallysignificant
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Myocardial Contusion DiagnosticStrategies• Controversy
Significantcontroversyexistsregardingtheimportanceofmakingthediagnosisinotherwisehemodynamicallynormalpatients
Cannotbedefinitivelyidentifiedshortofabiopsyperformedatbiopsy
Thepointofdiagnostictestingisnottodiagnosethepresenceofmyocardialcontusionbuttodefinealowriskpopulationthatcanbesafelydischargedfromtheemergencydepartment
• EKG EKGmaybenormalormaydemonstratenonspecificabnormalitiessuchassinustachycardia,RBBB(withinjuryofRV),AVBlock,Arrhythmias
Mostfrequentlyseenabnormalitiesincludesinustachycardiaandatrialextrasystolicbeats
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Myocardial Contusion DiagnosticStrategies(Continued)• CardiacEnzymes
CK/CK-MBareoflittlediagnosticutilitybecauseitwillbenon-specificallyincreasedintraumapatientsasaresultofskeletalmuscleinjury
Serumtroponinlevelsarehighlyspecificformyocardialinjuryandsomeauthorsrecommendtwosetsoftroponinmeasurements6hoursapartifnegativeisindicativeofalowriskstatus
• Echocardiography Echocardiographyisusefultoidentifywallmotionabnormalitiesandidentifyingassociatedlesionssuchasthrombi,pericardialeffusionandvalvulardisruption
• Radionucleotidestudies RarelyavailableintheEDandoflimitedbenefitbutwillidentifyunderperfusedareasoftheheartduetocontusion
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Myocardial Contusion Management• Thereislittlevaluetoadmittingandcarefullymonitoringpatientswithsuspectedmildcardiaccontusions
• Troponinissuggestedasameansofriskstratificationofpatientssuspectedofhavingamyocardialcontusion
• Increasedtroponinlevelssuggestahigherriskofdevelopingcardiaccomplicationsandwarrantsfurthermonitoringwithechocardiography,serialEKG’sandserialtroponinlevels
• NormalEKGandTroponinlevelat4-6hoursaftertheinjurycorrelateswithminimalriskofdevelopingcardiaccomplications
• Elevatedtroponinlevelsshouldbetreatedwithoxygen,cardiacmonitoringandanalgesia
Thrombolyticagentsandaspirinarecontraindicatedinthesettingofacutetrauma
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Myocardial Rupture Definition–Acutetraumaticperforationoftheventricles,atriabutincludespericardialrupture,lacerationorruptureofintraventicularseptum,papillarymusclesorvalves• Delayedrupturemayoccurweeksafterblunttrauma,probablyresultingfromnecrosisofacontusedorinfarctedareaofmyocardium
Epidemiology• MostcommonlytheresultofhighspeedMVC• 15%ofallfatalthoracicinjuries• Incidenceofcardiacruptureincasesofbluntchesttraumarangesfrom0.5%-2%
• Autopsyreviewsuggest20%ofpatientswillsurvive30minutesormoresuggestingrapiddiagnosismayhaveallowedthissubsettoreachtheoperatingroom
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Myocardial Rupture Pathophysiology• Ventriclesmostcommonlyrupture• Multiplechamberrupturein30%ofpatients• 20%ofnon-survivorsalsohaveaorticrupture• Proposedmechanismsofrupture
Decelerationshearingforcesactingonfixedattachments(IVC/SVCandatrium)
Upwarddisplacementofbloodandabdominalviscerafrombluntabdominalinjuryresultinginsuddenincreaseinintrathoracicpressure
Directcompressionofheartbetweensternumandvertebralbodies Lacerationfromriborsternalfracture Complicationofmyocardialcontusionwithsubsequentrupture
• Highassociationwithmulti-trauma–70%ofreportedsurvivorshadotherassociatedmajorinjuries
• Immediatesurvivalisrelatedtotheintegrityofthepericardium Intactpericardiumwithtamponadebleedingeffect Violatedpericardiumwillresultinimmediateexsanguination
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Myocardial Rupture ClinicalFeatures• Patientswilltypicallypresentwithevidenceofpericardialtamponadeandsubsequentrapiddeterioration
• Auscultation=“bruitdemoulin”=harshmurmur=splashingmillwheel=hemopericardium
• Findingssuggestiveofmyocardialrupture Hypotensiondisproportionatetosuspectedinjury Hypotensionunresponsivetofluidresuscitation MassiveHemothoraxunresponsivetothoracotomyandfluidresuscitation
Persistentmetabolicacidosis PericardialEffusiononechocardiographywithhypotension
Diagnosis• EmergencyDepartmentUltrasound• CXRsuggestiveofassociatedtraumaticinjuries
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Myocardial Rupture Management• ImmediateDecompressionofcardiactamponadeandhemorrhagecontrol• Pericardiocentesismaybeperformedastemporizingmeasureorasadiagnosticevaluationtool• Emergencydepartmentthoracotomymayberequiredinpatientswithrapiddeteriorationandcardiacarrest Hemorrhagecontrol=Fingerocclusion,FoleyCatheter,Vascularclamp GhanaEmergencyMedicineCollaborative
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Penetrating Cardiac Injury Penetratingcardiacinjuriesisoneofleadingcausesoftraumaticdeathinurbansettings
Rightventricle(43%)>Leftventricle(34%)duetoanatomiclocation
1/3affectmultiplechambers 5%haveanassociatedlaceratedcoronaryartery Outcomes• ExsanguinatingHemorrhage
Frequentlyexpirepriortoreachingemergencymedicalcare E.g.Gunshotwoundtotheheart
• CardiacTamponade Incasesofpenetratingcardiacinjury,actuallyofferssomedecreeofprotectionbyprovidingtamponadeeffecttomassiveexsanguination
Insomepatients,smallpericardialwoundcanactasawaytorelievepressurefromtamponadebyalsohelptamponadesevereexsanguination
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Penetrating Cardiac Injury PenetratingCardiacInjury• Knives=LowerEnergy• Bullets=HigherEnergy• RVclosesttosurfaceofchest
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Acute Pericardial Tamponade Epidemiology• Incidenceinpenetratingtraumatochestandupperabdomen=2%• 60-80%ofstabwoundstotheheartwillresultintamponade
Pathophysiology• Tamponaderesultsinincreasedintrapericardialpressureandvolume
• Increasingvolumeandpressurelimitsabilityofatriaandventriclestofillwithblood,eventuallyleadingtodecreasedstrokevolumeanddecreasedcardiacoutput
• Decreasedstrokevolumeandcardiacoutputresultinhypotensionanddecreasedpulsepressureresult
• HeartattemptstocompensatewithincreasedHRandtotalperipheralresistanceinanattempttomaintainadequatecardiacoutputandbloodpressure
• Clinicalpictureoftamponademayresultfromaslittleas60-100ccofbloodandclotsinthepericardium
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Acute Pericardial Tamponade ClinicalFeatures• Beck’sTriad
Hypotension Distendedneckveins Distantormuffledheartsounds
• Threedistinctclinicalpresentations Normotensive,tachycardicpatientwithelevatedCVP
• Hemorrhageconfinedtopericardialsac
Hypovolemicshockwithhypotension,tachycardiaandlowCVP• Significanthemorrhageoutsideofpericardialsac
Waxingandwaninghemodynamicmeasures• Intermittentlydecompressingtamponade
Diagnosis• Ultrasound=pericardialeffusion+RVcollapse
Ultrasound=98.1%Sensitive,99.9%specific• Electrocardiography=ElectricalAlternans• Radiography
Nottypicallyhelpful,mayseewaterbottleshapedheartorairfluidlevel
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Acute Pericardial Tamponade
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Acute Pericardial Tamponade Management• InitialResuscitation
VolumeexpansionwithcrystalloidviatwolargeboreIVcatheters
Bedsideechocardiographyfordiagnosis
• Pericardiocentesis Controversialtemporizingprocedure 5-10ccaspirationofbloodmayresultindramaticimprovementofclinicalcondition
Notbenignprocedure–lacerationofcoronaryarteryorlung,inductionofcardiacarrhythmias
• SurgicalRepair(Thoracotomy) Definitivetreatment
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Emergency Department Thoracotomy Drasticpotentiallylife-savingprocedure Indications
• PenetratingTraumaticCardiacArrest Cardiacarrestatanypointwithinitialsignsoflifeinthefield Bloodpressure<50mmHgafterresuscitation Severeshockwithclinicalsignsofcardiactamponade
• BluntTrauma Onlyifcardiacarrestintheemergencydepartment
• SuspectedAirEmbolus Goal=Determineifalife-threateningfixablelesionispresent
• CardiacTamponade,CardiacRupture• Vascularbleeding,Cross-ClampAorta
SurvivalRates• Cardiacarrestinthefield=0%• Cardiacarrestinemergencydepartment=30%• Agonalintheemergencydepartment=40%• Unresponsiveshockinemergencydepartment=50%
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Emergency Department Thoracotomy
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Blunt Traumatic Aortic Injury Epidemiology• Mostcommonvesselinjuredbyblunttrauma• IncreasingmortalityratesuggestingstrongassociationwithhighspeedMVC <1%(1947),15%(Current)
• 10-20%ofpatientssustainingbluntaorticinjurywillsurvivetemporarily• Meanage=33y/o,>70%aremen• 85%willsurviveifdiagnosisandsurgicalinterventionareprompt
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Blunt Traumatic Aortic Injury Pathophysiology• SiteofRupture
80-90%occurindescendingthoracicaortajustdistaltotheleftsubclavianartery• 25%incidenceofassociatedlethalcardiacinjuries
Othercommonareasofinjury• Distaldescendingaortaatlevelofthediaphragm• Mid-thoracicdescendingaorta• Originofleftsubclavianartery
Descendingaorta>Ascendingaorta Ascendingaortarupturehashighassociation(70-80%)withlethalcardiacinjuries• SurvivallongenoughtobeevaluatedinEDrare
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Blunt Traumatic Aortic Injury Pathophysiology• MechanismofInjury(DescendingAorta)
Descendingaortaisfixedandimmobileduetotetheringeffectoftheintercostalarteriesandligamentousarteriosum
Suddendeceleration,moremobileaorticarchmovesforwardproducingashearingforceontheaortaattheisthmus
Bendingstressattheisthmuscreatedbylateralobliquecompressionmayalsoresultinrupturebyflexionoftheaorticarchontheleftmainbronchusandpulmonaryartery
Otherauthorssuggestthatthesestressesarenotenoughtocausetheinjuryandtheinjuryresultsfrominferiorandposteriorrotationofanteriorthoracicosseousstructures(e.g.manubrium,clavicles,firstrib)thatsheartheaortaasitstrikesthevertebralcolumn
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Blunt Traumatic Aortic Injury Pathophysiology• Ascendingaortamechanism
Rapiddecelerationdisplacestheheartintoleftchestcausingashearingstressabovetheaorticvalvewithasuddenincreaseinintra-aorticpressure(waterhammereffect)
• OthermechanismsofAorticInjury Directlacerationbyfracturesofsternum,ribs,clavicle
Complicationofexternalcardiacmassage Fracturedislocationsofspine
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Blunt Traumatic Aortic Injury ClinicalFeatures• Considerinanypatientwithsuddendecelerationinjury• Clinicalmanifestationscanbedeceptiveandsubtle• Co-existinginjuriescanmaskthesignsandsymptomsofaorticinjury
• Mostcommonsymptomsareintrascapularorretrosternalpain• Othersymptoms
Dyspnea–trachealcompressionanddeviation Stridororhoarseness–compressionofrecurrentlaryngealnerve Dsyphagia-compressionoftheesophagus Extremitypain–decreasedextremityperfusion
• Signs–uncommonandnon-specific Hypertension(reflexresponsetostretchingstimulus) Harshsystolicmurmur Swellingatbaseofneck(rare)
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Blunt Traumatic Aortic Injury Diagnosis• Chestradiography
Increasedwidthofsuperiormediastinum• Seenin50-92%ofaorticruptures• Specificity=10%
Mediastinalwidth>8cminAPfilm Obscuredaorticknob Leftapicalpleuralcap PreviousbeliefthatnegativeCXRishighlypredicativeofnormalaortogramhasbeenrecentlychallengedandpatientswithsignificantmechanismsareatincreasedrisk
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Blunt Traumatic Aortic Injury
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Blunt Traumatic Aortic Injury Diagnosis• HelicalChestCT
100%sensitivityandspecificity PoorresultswithCTwerepreviouslyrelatedtoconventionalstyleCTscanners
• TransesophagealEchocardiography Fast,non-IVcontraststudythatcanbeperformedintheED(ifavailable) Allowsidentificationofintimalflapandperiaortichematoma Sensitivity=87%-100% Specificity=98-100%
• IntravascularUltrasound Smallultrasoundprobethatcanbeinsertedthroughfemoralarteryandguideduptotheaortatofindsubtleinjuries
Veryfewcentershavemodalityavailable
• Aortography Goldstandardforestablishingthediagnosis Intra-arterialinjectionofIVcontrastandwaspreviouslyrecommendedforanypatientwithsignificantbluntchesttraumaandabnormalCXR(beforehelicalCTscans)
RiskofcausingfurtherdamageifarterialcathetercrossessiteofinjuryGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Blunt Traumatic Aortic Injury HelicalCTImaging• Aorticarchdisruption
Aortogram• Pseudoaneuyrsmofdescendingaortaattheisthmus
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Blunt Traumatic Aortic Injury Management• EmergencyDepartment
Fixlifethreateninginjuriesfirst(ABCDE) Makethediagnosis Carefulregulationofbloodpressure(SBP=100-120mmHg)• Decreasetheshearingeffectofelevatedpulsepressure• IVBetablocker(Esmolol)
• SurgicalIntervention Definitivetherapy Incidenceofmortalityduringsurgery=20-30% Incidenceofparaplegia=5-7% Endovascularrepairisdevelopingastoolformanagementandinitialliteratureispromising
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Esophageal Perforation Epidemiology• MostrapidlyfatalperforationoftheGItractbecausedeathisnearly100%ifdiagnosisisdelayedpast24hours
• ClassicdescriptionwasbyBoerhaavein1724• Between1724–1940–Boerhaavesyndromewasnearly100%fatal• Withimprovedsurgicaltechniques,mortalityhasnowbeendecreasedto30%
Pathophysiology• Esophagealperforationisassociatedwithhighmortalitybecauseofthelackofanyserosalcoveringtotheesophaguswhichallowsdirectaccesstomediastinum
• Upperorcervicalperforations–extendintoretropharyngealspace• MidorLoweresophagealperforations–extenddirectlyintothemediastinum
• Drainageofesophagealcontentsresultsinchemicalandbacterialmediastinitis
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Esophageal Perforation Etiology• Iatrogenic
ComplicationofRigidorFlexibleEndoscopy EsophagealDilatation NasotrachealintubationorNasogastrictubeplacement DifficultEndotrachealIntubations
• ForeignBodies Foreignbodiescauseesophagealperforationthroughdirectlacerationorpressurenecrosisorascomplicationofendoscopicremoval
• CausticBurns Intentionaloraccidentalingestionofacidoralkali Perforationtypicallyoccurs4-14daysafteringestion Strongalkaliburns=Liquefactionnecrosis=Higherpotentialofperforation
Strongacidburns=Coagulationnecrosis=LowerpotentialofperforationGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Esophageal Perforation
Etiology(continued)• PenetratingandBluntTrauma
EsophagealTraumaoccursin5%ofpatientswithinjuriestotheneckbutonly1%ofblunttraumaduetoposteriorlocationofesophagus
Bluntesophagealtrauma<Penetratingesophagealtrauma
• SpontaneousRupture Boerhaave’sSyndrome Morethan80%aremiddleagedmenwhohaveingestedlargemealsandalcohol
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Esophageal Perforation Diagnosis• CXR–ClassicFeatures
MediastinalAirwithorwithoutsubcutaneousair
Left-sidedpleuraleffusion Pneumothorax Widenedmediastinum
• Radiographicevidencemaynotbepresentinearlyphaseofdisease
• Gastrografinesophagram(GoldStandard)
• Endoscopy Management• Earlydiagnosisiskey• Broadspectrumantibiotics• SurgicalRepair GhanaEmergencyMedicineCollaborative
AdvancedEmergencyTraumaCourse
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Questions?
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References Marx,JohnA.Rosen’sEmergencyMedicine6thEdition:ConceptsandClinicalPractice.NewYork.2006.
Rivers,Carol.PreparingfortheWrittenBoardExaminEmergencyMedicine.5thEdition.January2006
RobertsandHedges.ClinicalProceduresinEmergencyMedicine.4thEdition.Philadelphia.2004.
Tintinelli,Judith.EmergencyMedicine:Acomprehensivestudyguide.6thEdition.McGrawHill.2004.